Superiority of Magnesium and Vitamin B6 Over Magnesium Alone On Severe Stress in Healthy Adults With Low Magnesemia: A Randomized, Single-Blind Clinical Trial

RESEARCH ARTICLE
Superiority of magnesium and vitamin B6

over magnesium alone on severe stress in
healthy adults with low magnesemia: A
randomized, single-blind clinical trial
Etienne Pouteau ID1*, Marmar Kabir-Ahmadi2, Lionel Noah1, Andre Mazur3, Louise Dye4,
Juliane Hellhammer5, Gisele Pickering6, Claude Dubray6
a1111111111 1 Nutritionals, Sanofi, Gentilly, France, 2 Statistics, Sanofi, Gentilly, France, 3 Unité de Nutrition Humaine,
a1111111111 INRA, Université Clermont Auvergne, Clermont-Ferrand, France, 4 Nutrition and Behaviour Group, School of
a1111111111 Psychology, University of Leeds, Leeds, United Kingdom, 5 Contract Research and Saliva Lab, Daacro,
a1111111111 Trier, Germany, 6 Clinical Pharmacology Department, CHU, Université Clermont Auvergne, Clermont-
Ferrand, France
a1111111111
* etienne.pouteau@sanofi.com
OPEN ACCESS Abstract

Citation: Pouteau E, Kabir-Ahmadi M, Noah L,
Mazur A, Dye L, Hellhammer J, et al. (2018)
Superiority of magnesium and vitamin B6 over Introduction
magnesium alone on severe stress in healthy
Animal and clinical studies suggest complementary effects of magnesium and high-dose
adults with low magnesemia: A randomized,
single-blind clinical trial. PLoS ONE 13(12): pyridoxine (vitamin B6) on stress reduction. This is the first randomized trial evaluating the
e0208454. https://doi.org/10.1371/journal. effects of combined magnesium and vitamin B6 supplementation on stress in a stressed
pone.0208454 population with low magnesemia using a validated measure of perceived stress.
Editor: Yiqing Song, Indiana University Richard M
Fairbanks School of Public Health, UNITED
STATES
Methods
In this Phase IV, investigator-blinded trial (EudraCT: 2015-003749-24), healthy adults with
Received: August 14, 2018
Depression Anxiety Stress Scales (DASS-42) stress subscale score >18 and serum magne-
Accepted: November 16, 2018
sium concentration 0.45 mmol/L–0.85 mmol/L, were randomized 1:1 to magnesium–vitamin
Published: December 18, 2018 B6 combination (Magne B6 [Mg–vitamin B6]; daily dose 300 mg and 30 mg, respectively) or
Copyright: © 2018 Pouteau et al. This is an open magnesium alone (Magnespasmyl [Mg]; daily dose 300 mg). Outcomes included change in
access article distributed under the terms of the DASS-42 stress subscale score from baseline to Week 8 (primary endpoint) and Week 4,
Creative Commons Attribution License, which
and incidence of adverse events (AEs).
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited. Results
Data Availability Statement: Qualified researchers In the modified intention-to-treat analysis (N = 264 subjects), both treatment arms substan-
may request access to patient level data and related
study documents including the clinical study
tially reduced DASS-42 stress subscale score from baseline to Week 8 (Mg–vitamin B6,
report, study protocol with any amendments, blank 44.9%; Mg 42.4%); no statistical difference between arms was observed (p>0.05). An inter-
case report form, statistical analysis plan, and action (p = 0.0097) between baseline stress level and treatment warranted subgroup analy-
dataset specifications. Patient level data will be
sis (as per statistical plan); adults with severe/extremely severe stress (DASS-42 stress
anonymized and study documents will be redacted
to protect the privacy of trial participants. Further subscale score �25; N = 162) had a 24% greater improvement with Mg–vitamin B6 versus
details on Sanofi’s data sharing criteria, eligible Mg at Week 8 (3.16 points, 95% CI 0.50 to 5.82, p = 0.0203). Consistent results were
PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 1 / 17

Superiority of magnesium and vitamin B6 over magnesium alone on severe stress in healthy adults
studies, and process for requesting access can be observed in the per protocol analysis and at Week 4. Overall, 12.1% of Mg–vitamin B6
found at: https://www.clinicalstudydatarequest. treated and 17.4% of Mg-treated subjects experienced AEs potentially treatment related.
com
Funding: The study was funded by Sanofi-Aventis Conclusions

Groupe, Gentilly, France, the manufacturer of
MagneB6. The Sanofi-Aventis Groupe took an These findings suggest oral Mg supplementation alleviated stress in healthy adults with low
active a role in all aspects of this study, including magnesemia and the addition of vitamin B6 to Mg was not superior to Mg supplementation
the design, data collection and analysis, decision to
alone. With regard to subjects with severe/extremely severe stress, this study provides clini-
publish, and the preparation of the manuscript. JH
was employed by Daacro, a private contract cal support for greater benefit of Mg combined with vitamin B6.
research and saliva analysis laboratory during this
study. Daacro did not play any role in funding the
study design, data collection, decision to publish,
or preparation of the manuscript, however,
research materials and the laboratory premises
were used to analyse saliva samples for this study.
Introduction
Daacro provided support in the form of a salary for Magnesium is the second most abundant intracellular cation after potassium [1, 2]. It plays an
JH, but did not have any additional role in the study essential physiological role in the body as an enzymatic cofactor in over 600 biochemical reac-
design, data collection and analysis, decision to
tions [1]. The physiological impact of stress on intracellular and extracellular magnesium con-
publish, or preparation of the manuscript. The
specific role of JH is articulated in the ‘author centrations has been well described [3, 4]. Hormones released during stress, including
contributions’ section. catecholamines and corticosteroids, have been shown to enhance a shift of magnesium from
the intracellular to the extracellular space, leading to increased urinary excretion of magne-
Competing interests: I have read the journal’s
policy and the authors of this manuscript have the sium and subsequent decrease in serum magnesium concentrations [3, 5]. In turn, low serum
following competing interests to declare: CD magnesium concentrations increase the release of stress-associated hormones including cate-
reports no conflict of interest. AM reports cholamines, adrenocorticotrophic hormone and cortisol in response to stress, and affect their
consultancy fees from Sanofi, unrelated to this access to the brain, creating a vicious circle of reduced resistance to stress and further magne-
publication. LD has received research funding from
sium depletion [4, 6].
Sanofi and consultancy payments unrelated to this
publication. JH was employed by Daacro at the
The relationship between serum magnesium concentration and stress has been evidenced
time of this study, and has also received in a clinical trial that reported an association between low serum magnesium concentrations
consultancy fees and performed saliva analyses for and greater perceived stress in otherwise healthy women [7]. Other studies have documented a
Sanofi, unrelated to this publication. Daacro is a positive effect of magnesium supplementation on symptoms and biomarkers of stress. In a
private contract research and saliva analysis double-blind, randomized trial of 46 healthy adults aged 60–75 years, magnesium supplemen-
laboratory. Daacro did not play any role in funding
tation (magnesium 500 mg per day administered as magnesium oxide tablets for 8 weeks)
the study design, data collection, decision to
publish, or preparation of the manuscript, however, improved subjective measures of insomnia, which is recognized as a symptom of stress [8, 9].
research materials and the laboratory premises Magnesium supplementation over a period of one month (magnesium 500 mg per day in a
were used to analyse saliva samples for this trial magnesium oxide tablet) has also been shown to significantly decrease basal serum cortisol
and the company was reimbursed for any time or concentrations, a biomarker of stress, in students [10].
materials used relating to this study. EP, MK-A and
High-dose (100–300 mg daily) pyridoxine (vitamin B6) has also been proposed as an anti-
LN are employees of Sanofi. LN was employed by
Metabrain Research during the conduction of the
stress therapy; vitamin B6 exerts modulatory effects on neurotransmitters that affect depres-
trial and the early stages of the development of this sion and anxiety, and may reduce blood pressure and act peripherally to reduce the physiologi-
manuscript. This does not alter our adherence to cal impact of corticosteroid release [11]. In rodent studies, high-dose vitamin B6 was able to
PLOS ONE policies on sharing data and materials. correct low serum and tissue magnesium concentrations induced by dietary magnesium deple-
tion and prevent stress-induced gastric ulcers [12–14]. One proposed mechanism is that vita-
min B6 facilitates cellular uptake of magnesium, which both limits excretion and increases its
effectiveness (since the mineral is primarily an intracellular cation) [15, 16]. In light of the
direct roles of magnesium and vitamin B6 in the modulation of stress and associated pathways,
as well as their complementary effects, examination of the efficacy of magnesium and concom-
itant vitamin B6 supplementation in individuals with low concentrations of magnesium is war-
ranted. However, as recently reviewed, no randomized clinical trial to date has investigated the
efficacy of magnesium plus vitamin B6 supplementation on stress in such a population using a
validated measure of perceived stress as an outcome [17].

A combination of magnesium lactate dehydrate and pyridoxine hydrochloride in a 10:1

ratio (magnesium lactate dehydrate 300 mg/pyridoxine hydrochloride 30 mg) is available as an
over-the-counter supplement (e.g. Magne B6), and is indicated for the prevention and treat-
ment of magnesium deficiency and associated symptoms (including fatigue, mild anxiety, and
nervousness) (Magne B6 SmPC) [18]. This specific combination of magnesium and vitamin
B6 in a 10:1 ratio has been shown to provide faster relief of magnesium-deficiency symptoms
than magnesium alone in magnesium-deficient animals [12]. The objective of the current trial
was to compare this magnesium–vitamin B6 combination versus magnesium alone in stressed
healthy adults with suboptimal serum magnesium concentrations using the stress subscale of
the validated Depression Anxiety Stress Scales (DASS-42) self-assessment tool [19].
Methods
Trial design
This was an 8-week, Phase IV, randomized, controlled, investigator-blinded, parallel-group trial
stratified by sex (EudraCT Number: 2015-003749-24) (Fig 1). The trial was carried out at 4 clini-
cal trial centers in France. Healthy subjects completed a pre-trial telephone interview within 1
week prior to screening; the baseline visit took place <2 weeks after the screening visit (Fig 2).
The 8-week treatment period comprised visits at Week 4 and Week 8. Subjects were randomized
Fig 1. CONSORT flowchart. AE, adverse event; Mg, magnesium.

https://doi.org/10.1371/journal.pone.0208454.g001

Fig 2. Trial design. � Four subjects did not proceed to the treatment phase and did not receive any investigational product due to major protocol
deviations. Mg, magnesium.
1:1 to treatment with either the magnesium–vitamin B6 (Mg–vitamin B6) combination or mag-
nesium (Mg) alone. Subjects were randomly divided at baseline in order to avoid systematic dif-
ferences with respect to known or unknown variables that could affect outcomes.
Standard protocol approvals, registration and participant consents

The protocol complied with recommendations of the Declaration of Helsinki, amended by the
64th World Medical Association General Assembly, Fortaleza, Brazil, October 2013, and the
International Conference on Harmonization (ICH) guidelines for good clinical practice (GCP),
all applicable laws, rules and regulations. The protocol also complied with the laws and regula-
tions, as well as any applicable guidelines, from France, where the trial was conducted. Ethical
approval was granted by The Ethical Committee (comité de protection des personnes) at Le Cen-
tre Hospitalier Universitaire (CHU), France. All subjects provided written informed consent.
Subjects
Subjects were between 18 and 50 years of age with moderate to extremely severe stress at
screening, defined as a DASS-42 stress subscale score of >18 [20]. Additionally, subjects must
have presented with suboptimal serum magnesium concentrations (assessed locally at each of
the trial sites), defined as serum magnesium concentrations between 0.45 mmol/L and 0.85
mmol/L; these were measured locally at the investigation centers. The upper limit of the serum
magnesium cut-off was chosen based on previous work establishing an evidence-based refer-
ence interval (central 95th percentile) as 0.75 mmol/L to 0.95 mmol/L with a mean concentra-
tion of 0.85 mmol/L. The serum magnesium cut-off of 0.85 mmol/L has been previously
determined as the lower limit adjusted to a value for health in a trial of over 15,000 subjects
[21]. At screening, magnesium concentrations were assessed with blood serum samples. Dur-
ing the study (baseline, Week 4 and Week 8), magnesium concentrations were assessed in the
erythrocytes; erythrocytes are thought to accurately represent magnesium cell content within
the body and provide an accurate reflection of the whole body magnesium status. Additional

inclusion criteria were, a body mass index (BMI) of >18.5 and �29.9 kg/m2, and the use of an
effective method of contraception during the trial period for female subjects. Key exclusion cri-
teria included: exposure to therapies prohibited by the protocol (including levodopa, quini-
dine, and proton-pump inhibitors) within 3 months prior to screening; concomitant
conditions or diseases that could make subjects non-evaluable for the primary endpoint; severe
hypomagnesemia (defined as serum magnesium of �0.45 mmol/L) [21]; participant-reported
moderate or severe kidney failure; confirmed diagnosis of type 1 or 2 diabetes; any known
addiction to drugs and alcohol; alcohol intake of �3 drinks per day.
Interventions
Each participant received coated tablets of either Mg–vitamin B6 combination (Magne B6; 470
mg magnesium lactate dihydrate and 5 mg pyridoxine hydrochloride) or Mg alone (Magne-
spasmyl [Mg]; 465.4 mg magnesium lactate dihydrate). Tablets were self-administered orally,
with subjects taking 6 coated tablets per day (corresponding to approximately 300 mg elemen-
tal magnesium with or without 30 mg vitamin B6) divided into 3 intakes (2 tablets during each
meal [breakfast, lunch, and dinner]) over a period of 8 weeks.
Tablets were provided in treatment sets with 50 tablets, dispatched in 5 blister packs of 10
tablets each. Subjects received 4 treatment kits at randomization for the following 4 weeks,
after which they received an additional 4 treatment kits at the Week 4 visit for use until the
end of the trial.
Objectives
The primary objective was to compare magnesium in combination with vitamin B6 supple-
mentation versus magnesium alone on stress, evaluated by the stress subscale from the DASS-
42 test, in healthy adults with stress and suboptimal serum magnesium concentrations. A sec-
ondary objective was to evaluate the safety profile of the Mg–vitamin B6 combination versus
Mg alone, as determined by the incidence of adverse events (AEs).
Outcome variables and assessments

The primary outcome variable was change in the DASS-42 stress subscale score from baseline
to Week 8. A secondary outcome variable was change in the DASS-42 stress subscale score
from baseline to Week 4. Depression and anxiety subscales of DASS-42 were also evaluated
during the trial but these data will be reported in separate publications. Subjects completed the
DASS-42 questionnaire at screening, baseline, Week 4 and Week 8.
The DASS-42 is a 42-item, clinically validated questionnaire that includes three subscales
designed to measure negative emotional states of depression, anxiety and stress over the previ-
ous week [18]. The stress component of DASS-42 comprises 14 questions with a 4-point scale
for self-reported scoring: 0 = did not apply to me at all; 1 = applied to me to some degree, or
some of the time; 2 = applied to me a considerable degree, or a good part of the time; 3 = applied
to me very much, or most of the time [19, 20].
Treatment adherence was tracked by counting dispensed and unused tablets at Week 4 and
Week 8 visits. A participant was considered non-adherent if they did not dispense the planned
dose as required by the protocol: i.e., 8 weeks of treatment; oral route; 6 coated tablets per day;
2 coated tablets to be swallowed during each meal.
Safety outcomes included incidence of AEs, treatment-related AEs, and serious adverse
events (SAEs). AEs were coded according to the Medical Dictionary for Regulatory Activities
(MedDRA), version 20.0.

Sample size
An overall sample size of 268 (134 in each treatment arm) was selected to obtain 119 evaluable
subjects per treatment arm (assuming 10% of subjects would be non-evaluable), and achieve
80% power to detect a difference of 3 points on the DASS-42 stress subscale score change from
baseline at Week 4 and Week 8 between intervention arms (delta of superiority corresponding
to ~15% of baseline value, which was expected to be ~20). Group standard deviations (SD) of 8
points were estimated with a significance level (alpha) of 0.05 using a two-sided equal-variance
t-test and a Mann–Whitney test, and assuming normal distribution.
The clinically relevant difference of 3 points was defined with expert clinicians. The SD esti-
mation was based on the evaluation of DASS-42 stress subscale score of “emailed standardized
cognitive behavioral treatment of work-related stress” [22].
Randomization and blinding

The randomization sequence was centralized and generated automatically under the responsi-
bility of the French Clinical Study Unit of Sanofi using validated software (SAS 9.2), and treat-
ments were packaged according to this sequence. At randomization, the trial site contacted an
Interactive Web Response System to allocate treatment kits to subjects. Treatment kits were
indistinguishable and labelled with randomized treatment kit numbers. Investigators were
blinded by ensuring that treatment dispensing and treatment return were handled separately.
Statistical methods
The modified Intention-To-Treat (mITT) population was defined as all subjects with an evalu-
able DASS-42 stress subscale score at baseline and at least one other time point during the
treatment period. The Per Protocol (PP) population was defined as all subjects included in the
mITT analysis without any major protocol deviations.
Of note, the mITT population comprised some subjects who had a baseline DASS-42
stress subscale score �18. This can be attributed to variations in DASS-42 stress subscale
score between screening and baseline (~two weeks occurred between screening and base-
line). Therefore, the statistical analysis plan was amended after the database lock based on a
decision from the scientific committee, such that the PP population should include all sub-
jects in the mITT without any major protocol violations, and with a DASS-42 stress subscale
score >18 at baseline.
The population included in the Safety Set (SS) comprised all subjects included in the trial
with at least one consumption of trial product and was used for safety evaluations.
Differences between treatment arms in change from baseline to Week 4 or Week 8 in
DASS-42 stress subscale scale score were calculated by means of a repeated measures analysis
of covariance (ANCOVA), with DASS-42 stress subscale score at baseline and stratification
factor (sex) as covariates, and visit and interaction between visit and treatment group and
interaction between baseline value and treatment group as fixed effects.
Adjusted mean was calculated from model ANCOVA adjusted by baseline value of DASS-
42 and the interaction of baseline and treatment.
Subgroup analyses
Based on European Medical Agency (EMA) guidelines for the adjustment of baseline covari-
ates [23], the statistical analysis plan was amended after the blinded database lock to include
subgroup analyses of primary and secondary efficacy endpoints by baseline stress level, as a
significant interaction (p < 0.05) was present between baseline DASS-42 stress subscale scores

and treatment (assessed firstly as a continuous variable and then categorically by class [‘normal
and moderate stress’ versus ‘severe and extremely severe stress’]).
Results
Participant disposition
Between May 2016 and January 2017, 854 subjects were screened and 268 were enrolled (134
in each treatment arm) (Fig 1). Two subjects in each treatment arm received no trial treat-
ment, and were excluded from the mITT and PP analysis. Of note, 26 subjects (13 in each
arm) in the mITT analysis had baseline DASS-42 stress subscale scores �18 despite the inclu-
sion criteria used at screening. This was due to variation in stress levels between screening and
baseline. These 26 subjects were excluded from the PP analysis in line with statistical analysis
plan, in addition to a further five subjects (two in the Mg–vitamin B6 combination arm and
three in the Mg alone arm) who were excluded due to an observed treatment adherence of
�75%, defined as a major protocol deviation. For the subgroup analyses specified in the
results, the 26 subjects with baseline DASS-42 stress subscale scores �18 were included in the
mITT but excluded from the PP analysis. Overall, 260 subjects (130 in each arm) completed
the trial (Fig 1).
Baseline demographics and characteristics

Mean (SD) age at baseline was 31.6 (8.5) years, and mean BMI was 23.0 kg/m2. The majority
(74%) of subjects were female. Demographic characteristics were similar across treatment
arms (Table 1). The distribution of subjects across DASS-42 stress subscale levels was also sim-
ilar in each treatment arm, with approximately 60% in each group classified as having severe
or extremely severe stress (Table 2). There was no association between DASS-42 score and
Table 1. Participant demographic and disease characteristics at baseline (mITT population).

Parameter Mg–vit B6 combination (N = 132) Mg (N = 132) Total (N = 264)
Age (years), mean (SD) 31.2 (8.4) 32.1 (8.6) 31.6 (8.5)
Sex female, n (%) 98 (74.2) 97 (73.5) 195 (73.9)
BMI, kg/m2, mean (SD) 23.0 (3.0) 22.9 (2.7) 23.0 (2.8)
BMI category, n (%)
Normal (18.5–<25 kg/m2) 101 (76.5) 102 (77.3) 203 (76.9)
Overweight (25–<30 kg/m2) 31 (23.5) 30 (22.7) 61 (23.1)
Systolic blood pressure (mmHg), mean (SD) 118.2 (13.4) 116.7 (11.1) 117.4 (12.3)
Diastolic blood pressure (mmHg), mean (SD) 73.9 (9.1) 72.8 (8.3) 73.4 (8.7)
Heart rate (bpm), mean (SD) 68.1 (12.8) 67.6 (11.6) 67.9 (12.2)
Serum Mga (mmol/L)
Mean (SD) 0.80 (0.0) 0.80 (0.0) 0.80 (0.04)
Median (Min, Max) 0.80 (0.7, 0.8) 0.80 (0.7, 0.8) 0.82 (0.66, 0.84)
Erythrocyte Mg (mmol/L), mean (SD) 1.80 (0.30) 1.80 (0.40) 1.83 (0.31)
Serum B6 (nmol/L), mean (SD) 50.6 (68.8) 46.5 (27.6) 48.6 (52.3)
DASS-42 stress subscale score, mean (SD) 27.7 (7.3) 27.6 (7.0) 27.7 (7.1)
DASS-42 total score, mean (SD) 58.3 (21.3) 58.4 (20.9) 58.4 (20.9)
a
At screening visit;
BMI, body mass index; bpm, beats per minute; DASS, Depression Anxiety Stress Scales; mITT, modified intention-to-treat; Mg, magnesium; SD, standard deviation; Vit
B6, vitamin B6.
https://doi.org/10.1371/journal.pone.0208454.t001

Table 2. Distribution of DASS-42 stress subscale scores at baseline and Week 8 (mITT population).
Baseline Week 8
DASS-42 stress score Mg–vit B6 combination Mg Total Mg–vit B6 combination Mg Total
(N = 132) (N = 132) (N = 264) (N = 132) (N = 132) (N = 264)
Normal (scorea 0–14), n (%) 4 (3.0) 6 (4.5) 10 (3.8) 75 (57.3) 69 (53.1) 144 (55.2)
Mild (scorea 15–18), n (%) 9 (6.8) 7 (5.3) 16 (6.1) 18 (13.7) 21 (16.2) 39 (14.9)
Moderate (scorea 19–25), n (%) 41 (31.1) 35 (26.5) 76 (28.8) 29 (22.1) 17 (13.1) 46 (17.6)
Severe (scorea 26–33), n (%) 46 (34.8) 59 (44.7) 105 (39.8) 7 (5.3) 15 (11.5) 22 (8.4)
Extremely severe (scorea 34–42), 32 (24.2) 25 (18.9) 57 (21.6) 2 (1.5) 8 (6.2) 10 (3.8)
n (%)
a
Stress subscale score
DASS, Depression Anxiety Stress Scale; mITT, modified intention-to-treat; Mg, magnesium; Vit B6, vitamin B6.
overweight (25–<30 kg/m2) status (mean [SD] DASS-42 for those not overweight versus over-
weight: 27.9 [7.1] versus 26.9 [7.0]; p > 0.05).
Overall, 39% of subjects in the Mg–vitamin B6 combination arm and 40% in the Mg arm
reported at least one medication prior to trial entry, 39% in both arms had ongoing medication
at baseline, and 25% and 21%, respectively, started at least one medication between baseline
and Week 8. None of the prior medications have any known interaction with the trial product
or effect on stress.
Treatment adherence
Between baseline randomization and Week 8, mean (SD) assumed treatment adherence was
94% (7.1) in the Mg–vitamin B6 combination arm and 93.0% (9.2) in the Mg arm; 96% of sub-
jects (127/132) in each arm had an assumed treatment adherence of �80%.
Efficacy
Overall change from baseline in DASS-42 stress subscale score. In the mITT popula-
tion, both treatments reduced DASS-42 stress subscale score from baseline to Week 8, reduc-
ing the overall proportion of subjects with severe or extremely severe stress at baseline from
approximately 60% to approximately 12% (Table 2). The DASS-42 stress subscale score
improved by 44.9% from a mean (SD) of 27.7 (7.3) points at baseline to 14.5 (7.4) points at
Week 8 in the Mg–vitamin B6 combination arm, representing a change in adjusted mean of
−12.44 points (95% confidence interval [CI] −13.83 to −11.05). Scores also improved in the
Mg group, by 42.4%, from 27.6 (7.0) points at baseline to 15.3 (9.5) points at Week 8, with a
change in adjusted mean of −11.72 points (95% CI −13.10 to −10.33). The difference between
treatment arms was not statistically significant (0.72 points, 95% CI −1.15 to 2.59, p > 0.05)
(Table 3). Similar findings were observed in the PP population with no statistically significant
difference between treatment arms (1.06 points, 95% CI −0.99 to 3.10, p > 0.05 (Table 3).
In the mITT population, both treatment arms improved DASS-stress subscale score from
baseline to Week 4 (Mg–vitamin B6, −8.94 points, 95% CI −10.22 to −7.65; Mg, −7.58, 95% CI
−8.86 to −6.30); the difference between treatment arms was not statistically significant (1.35
points, 95% CI −0.36 to 3.06, p > 0.05) (Table 3). Similar improvements from baseline to
Week 4 were observed in the PP population, with no statistically significant difference between
treatment arms (1.55 points, 95% CI −0.33 to 3.43, p > 0.05; Table 3).
Change in DASS-42 stress subscale score in baseline stress severity subgroups. Accord-
ing to recent EMA guidelines, the identification of heterogeneous benefits within samples

Table 3. Change in DASS-42 stress subscale score from baseline to Week 4 and to Week 8.
mITT population Mg–vit B6 combination (N = 132) Mg (N = 132)
Change from baseline to Week 4a (95% CI) −8.94 (−10.22 to −7.65) −7.58 (−8.86 to −6.30)
Difference between treatment arms 1.35 (−0.36 to 3.06), p = 0.1203
Change from baseline to Week 8a (95% CI) −12.44 (−13.83 to −11.05) −11.72 (−13.10 to −10.33)
PP population Mg–vit B6 combination (N = 117) Mg (N = 116)
Change from baseline to Week 4ab (95% CI) −9.59 (−11.03 to −8.15) −8.04 (−9.45 to −6.63)
Change from baseline to Week 8ab (95% CI) −13.26 (−14.81 to −11.71) −12.21 (−13.73 to −10.68)
a
Difference from baseline in adjusted mean.
b
Subjects with subscale scores �18 baseline were excluded from the PP population.
CI, confidence interval; DASS, Depression Anxiety Stress Scale; mITT, modified intention-to-treat; Mg, magnesium;
PP, per protocol; Vit B6, vitamin B6.
warrants additional subgroup analyses [23], thus a subgroup analysis was performed, in line
with the statistical analysis plan. The interaction test to assess association between DASS-42
stress subscale score at baseline and treatment showed a statistically significant association in
both the mITT population (p = 0.0097) and the PP population (p = 0.0171). Therefore, an
analysis of change in DASS-42 stress subscale score by subgroup according to baseline score
was carried out in both the mITT and PP populations.
For mITT population, the subgroups were defined as normal to moderate stress and severe
to extremely severe stress; in the PP population the subgroups were defined as moderate stress
and extreme to extremely severe stress. The severe to extremely severe stress subgroup com-
prised subjects with baseline DASS-42 stress subscale scores between 26 and 42 (mITT and
PP); the normal to moderate stress subgroup comprised subjects with baseline stress subscale
scores between 0 and 25 (mITT) [20]; the moderate stress subgroup comprised subjects with
scores between 19 and 25 and did not include subjects with baseline DASS-42 stress subscale
scores �18, who were already excluded from the PP as per the statistical analysis plan. For
both mITT and PP population analyses, baseline DASS-42 stress subscale scores were similar
between treatment arms in the severe and extremely severe stress subgroup (mITT: Mg–vita-
min B6 combination, n = 78; Mg, n = 84 and PP: Mg–vitamin B6 combination, n = 76; Mg
n = 84) (Fig 3) and the normal to moderate (mITT population) and moderate (PP population)
stress subgroups (mITT: Mg–vitamin B6 combination, n = 54; Mg, n = 48 and PP; Mg–vitamin
B6 combination n = 41; Mg, n = 32) (Fig 3).
In the mITT population, both treatment arms in the severe and extremely severe stress sub-
group had an improvement in DASS-42 subscale score from baseline to Week 8. The Mg–vita-
min B6 arm had a 50.1% improvement (−16.36 points, 95% CI, −18.27 to −14.44) and the Mg
arm had a 41.3% improvement (−13.20 points, 95% CI, −15.05 to −11.36). There was a statisti-
cally significant improvement from baseline to Week 8 in Mg–vitamin B6-treated subjects
compared with the Mg group (Fig 3A). The improvement was 23.9% greater (3.16 points, 95%
CI 0.50 to 5.82, p = 0.0203) for the Mg–vitamin B6 combination group versus the Mg group.
There was no significant difference between treatment arms in subjects with normal to moder-
ate stress (−2.36 points, 95% CI −4.99 to 0.27, p > 0.05) (Fig 3A).
Similar results were observed in the PP population (Fig 3B). In subjects with severe or
extremely severe stress, both treatment arms improved DASS-42 stress subscale score. The

Fig 3. Change in DASS-42 stress subscale score from baseline to Week 8 in the mITT (A) and PP (B) subgroup populations. CI, confidence interval; DASS,
Depression Anxiety Stress Scale; Mg, magnesium; mITT, modified intention-to-treat; PP, per protocol; Vit B6, vitamin B6.
Mg–vitamin B6 arm had an improvement of 49.4% (−16.09 points, 95% CI −18.02 to −14.16)
and the Mg arm had an improvement of 41.3% (−13.20 points, 95% CI−15.04 to −11.36). A

statistically significant 21.9% (2.89 points, 95% CI 0.22 to 5.56, p = 0.0339) greater improve-
ment from baseline to Week 8 was observed in Mg–vitamin B6-treated versus Mg-treated sub-
jects. There was no significant difference between treatment arms in subjects with moderate
stress (−1.96 points; 95% CI −5.11 to 1.20, p > 0.05).
Changes from baseline to Week 4 are shown in Table 4. In the mITT population, in sub-
jects with severe or extremely severe stress, the improvement from baseline was 38.2% (3.37
points; 95% CI 1.02 to 5.73) greater with Mg–vitamin B6 combination compared with Mg, and
the difference in change between treatments was statistically significant (p = 0.0053). In sub-
jects with normal to moderate stress, the change from baseline was not significantly different
between treatment arms (−1.22 points; 95% CI −3.73 to 1.29; p > 0.05).
Change from baseline to Week 4 in the PP population was consistent with the mITT popu-
lation findings (Table 4). In subjects with severe or extremely severe stress, the improvement
from baseline was 39.6% (3.50 points, 95% CI 1.13 to 5.86) greater with the Mg–vitamin B6
combination compared with Mg, and the difference was statistically significant (p = 0.0041).
In subjects with moderate stress, there was no significant difference between treatment arms
(−1.79 points, 95% CI −4.89 to 1.32; p > 0.05).
Safety
Overall, 41% (54/132) of subjects in the Mg–vitamin B6 combination arm and 40% (53/132) in
the Mg arm experienced at least one AE. In total, 12% (16/132) of subjects in the Mg–vitamin
B6 combination group and 17% (23/132) in the Mg group experienced at least one AE consid-
ered possibly related to trial treatment, as assessed by the trial physician. The most common
treatment-related AE was diarrhea, reported by 4.5% (6/132) of subjects in the Mg–vitamin B6
combination arm and 7.6% (10/132) in the Mg arm (Table 5). One (0.8%) subject in the Mg
arm had at least one AE of severe intensity (gastroenteritis); no such events occurred in the
Mg–vitamin B6 combination arm.
Treatment dose was interrupted for two subjects in the Mg–vitamin B6 combination arm
and four in the Mg arm due to AEs. All six subjects recovered from the AEs. One participant
Table 4. Change in DASS-42 stress subscale score from baseline to Week 4 by DASS-42 subscale subgroup score at baseline.
mITT population Severe to extremely severe stress (N = 162) Normal to moderate stress (N = 102)
Mg–vit B6 combination Mg (N = 84) Mg–vit B6 combination Mg (N = 48)
(N = 78) (N = 54)
Baseline, adjusted mean (SE) 32.67 (0.52) 31.93 (0.47) 20.53 (0.52) 20.18 (0.58)
Week 4, adjusted mean (SE) 20.47 (0.96) 23.10 (0.91) 14.90 (0.87) 13.33 (0.94)
Change in adjusted mean (95% CI) −12.21 (−13.90 to −10.51) −8.83 (−10.47 to −5.63 (−7.35 to −3.91) −6.85 (−8.68 to
−7.20) −5.03)
Difference in change in adjusted mean between arms 3.37 (1.02 to 5.73), p = 0.0053 −1.22 (−3.73 to 1.29), p = 0.3354
(95% CI)
PP population Severe to extremely severe stress (N = 160) Moderate stress (N = 73)
Mg–vit B6 combination Mg (N = 84) Mg–vit B6 combination Mg (N = 32)
(N = 76) (N = 41)
Baseline, adjusted mean (SE) 32.57 (0.53) 31.92 (0.47) 22.13 (0.34) 21.94 (0.40)
Week 4, adjusted mean (SE) 20.25 (0.97) 23.08 (0.91) 15.88 (1.04) 13.90 (1.18)
Change in adjusted mean (95% CI) −12.33 (−14.04 to −10.61) −8.83 (−10.46 to −6.24 (−8.30 to −4.19) −8.03 (−10.36 to
−7.20) −5.70)
Difference in change in adjusted mean between arms 3.50 (1.13 to 5.86), p = 0.0041 −1.79 (−4.89 to 1.32), p = 0.2550
(95% CI)
CI, confidence interval; DASS, Depression Anxiety Stress Scale; mITT, modified intention-to-treat; Mg, magnesium; PP, strict per protocol analysis; SE, standard error;
Vit B6, vitamin B6. Standard error rather than standard deviation was calculated for subgroups to account for the means being adjusted.

Table 5. Treatment-related adverse events occurring in �1% of the total population (SS).
System Organ Class, Preferred Term Mg–vit B6 combination (N = 132) Mg (N = 132) Total (N = 264)
Subjects with �1 TRAE, TRAEs, Subjects with �1 TRAE, TRAEs, Subjects with �1 TRAE, TRAEs,
n (%) n (%) n (%) n (%) n (%) n (%)
Total 16 (12.12) 26 (100) 23 (17.42) 43 (100) 39 (14.77) 69 (100)
Gastrointestinal disorders 11 (8.33) 18 18 (13.64) 36 29 (10.98) 54
(69.23) (83.72) (78.26)
Abdominal discomfort 1 (0.76) 1 (3.85) 0 (0.00) 0 (0.00) 1 (0.38) 1 (1.45)
Abdominal distension 2 (1.52) 2 (7.69) 0 (0.00) 0 (0.00) 2 (0.76) 2 (2.90)
Abdominal pain 3 (2.27) 3 (11.54) 6 (4.55) 10 9 (3.41) 13
(23.26) (18.84)
Abdominal pain upper 0 (0.00) 0 (0.00) 2 (1.52) 2 (4.65) 2 (0.76) 2 (2.90)
Constipation 0 (0.00) 0 (0.00) 1 (0.76) 1 (2.33) 1 (0.38) 1 (1.45)
Diarrhea 6 (4.55) 6 (23.08) 10 (7.58) 19 16 (6.06) 25
(44.19) (36.23)
Dry mouth 1 (0.76) 1 (3.85) 0 (0.00) 0 (0.00) 1 (0.38) 1 (1.45)
Dysphagia 1 (0.76) 1 (3.85) 0 (0.00) 0 (0.00) 1 (0.38) 1 (1.45)
Feces soft 3 (2.27) 3 (11.54) 2 (1.52) 2 (4.65) 5 (1.89) 5 (7.25)
Flatulence 0 (0.00) 0 (0.00) 1 (0.76) 1 (2.33) 1 (0.38) 1 (1.45)
Frequent bowel movements 1 (0.76) 1 (3.85) 0 (0.00) 0 (0.00) 1 (0.38) 1 (1.45)
Nausea 0 (0.00) 0 (0.00) 1 (0.76) 1 (2.33) 1 (0.38) 1 (1.45)
General disorders and administration site 1 (0.76) 1 (3.85) 0 (0.00) 0 (0.00) 1 (0.38) 1 (1.45)
conditions
Asthenia 1 (0.76) 1 (3.85) 0 (0.00) 0 (0.00) 1 (0.38) 1 (1.45)
Metabolism and nutrition disorders 0 (0.00) 0 (0.00) 1 (0.76) 1 (2.33) 1 (0.38) 1 (1.45)
Increased appetite 0 (0.00) 0 (0.00) 1 (0.76) 1 (2.33) 1 (0.38) 1 (1.45)
Nervous system disorders 2 (1.52) 2 (7.69) 5 (3.79) 5 (11.63) 7 (2.65) 7 (10.14)
Dizziness 0 (0.00) 0 (0.00) 1 (0.76) 1 (2.33) 1 (0.38) 1 (1.45)
Headache 2 (1.52) 2 (7.69) 3 (2.27) 3 (6.98) 5 (1.89) 5 (7.25)
Hypersomnia 0 (0.00) 0 (0.00) 1 (0.76) 1 (2.33) 1 (0.38) 1 (1.45)
Psychiatric disorders 2 (1.52) 2 (7.69) 0 (0.00) 0 (0.00) 2 (0.76) 2 (2.90)
Sleep disorder 2 (1.52) 2 (7.69) 0 (0.00) 0 (0.00) 2 (0.76) 2 (2.90)
Skin and subcutaneous tissue disorders 3 (2.27) 3 (11.54) 1 (0.76) 1 (2.33) 4 (1.52) 4 (5.80)
Dermatitis acneiform 1 (0.76) 1 (3.85) 1 (0.76) 1 (2.33) 2 (0.76) 2 (2.90)
Rash papular 2 (1.52) 2 (7.69) 0 (0.00) 0 (0.00) 2 (0.76) 2 (2.90)
Mg, magnesium; SS, safety set; TRAE, treatment-related adverse event; Vit B6, vitamin B6.
in the Mg arm experienced a SAE (severe gastroenteritis that led to hospitalization), and was
subsequently withdrawn from the trial. This SAE was considered not to be related to trial med-
ication as assessed by the trial physician; therefore, the participant received the treatment until
trial withdrawal. No deaths occurred during the course of the trial.
Discussion
This is the first randomized clinical trial to evaluate the effects of magnesium and vitamin B6
(Mg–vitamin B6) supplementation versus magnesium alone (Mg) on stress in individuals with
stress and low serum magnesium concentrations using a validated psychometric measure of
perceived stress (the DASS-42 stress subscale). Both treatments were administered in accor-
dance with the recommended posology, relevant for the prevention and treatment of magne-
sium deficiency and associated symptoms, including stress-related symptoms like mild

anxiety, and nervousness. The 300 mg elemental magnesium provided by the treatments cov-
ers 75–100% of the recommended daily intake [24], and a dosing regimen spread over two-to-
three intakes per day is generally recommended to improve magnesium bioavailability [25].
Formulated as magnesium salt of organic acid (lactate), both Magne B6 and Magnespasmyl
have greater solubility than magnesium salts of inorganic acids, and are therefore associated
with better absorption and increased magnesium bioavailability [26–29]. Although previous
results from experimental clinical trials were suggestive of a beneficial effect of the specific
combination of magnesium lactate and vitamin B6 in a 10:1 ratio on subjective mood follow-
ing several weeks of treatment [17], no randomized clinical trial has previously investigated
the efficacy of such a formula on perceived stress in healthy adults.
Both interventions rapidly reduced stress from baseline, as indicated with a reduction in
DASS-42 stress subscale score across both treatment arms of approximately 30% (~8 points) at
Week 4 and 40% (~12 points) at Week 8 in the whole trial population (Table 3). Given that
the mean (SD) DASS-42 stress subscale score across all subjects at baseline was 27.7 (7.1), this
represents a clinically relevant reduction, being sufficient to move a participant with severe
stress to the moderate category and a participant with moderate stress to the mild category. At
Week 8, the stress reduction with Mg–vitamin B6 treatment was approaching 50% compared
with baseline in severely stressed individuals. Numerous studies have confirmed the robust
psychometric properties of the DASS-42 test in both adult and elderly populations with mood
or anxiety disorders, with internal consistency ranging from 0.88 to 0.95 for the stress subscale
[19, 30, 31]. The large magnitude of effect observed in this trial provides strong evidence for
the benefits of Mg supplementation in stressed individuals with low serum magnesium; how-
ever, a placebo-controlled trial would be required to determine the true extent of benefits,
especially given the large placebo effects observed in previous studies [17].
The benefits of magnesium in this population with low serum magensium concentration
could be attributed to the effect of Mg levels on resistance to stress. Catecholamines and corti-
costeroids released during periods of stress decrease serum magnesium concentration through
urinary excretion [3,5]. Conversely, low serum magnesium concentration increases the release
of these same stress-associated hormones, leading to a positive feedback loop that enhances
both the release of stress hormones and the depletion of magnesium [4,6].
Although superiority of Mg–vitamin B6 versus Mg was not demonstrated in the whole pop-
ulation, a statistically significant interaction was identified between baseline DASS-42 stress
subscale score and treatment. According to recent regulatory guidance and EMA guidelines,
the identification of a qualitative interaction that illustrates heterogeneous benefits within trial
populations warrants further subgroup analyses [23, 32], thus a subgroup analysis was per-
formed in line with the statistical analysis plan. Although a possible bias should be considered,
due to the fact that randomization was performed on the initial whole population and not on
the subgroups, this analysis revealed significantly greater reductions in the symptoms of stress
with Mg–vitamin B6 than with Mg alone in subjects with severe and extremely severe stress,
but no difference in those with normal to moderate stress. The majority of the improvements
in DASS-42 stress subscale score occurred between baseline and Week 4 for both treatment
arms, with incremental improvements seen between Week 4 and Week 8. Of note, in subjects
with severe or extremely severe stress, Mg–vitamin B6 reduced stress levels at Week 4 to a sim-
ilar extent (mITT, 37%; PP, 38%) (Table 3) as Mg alone at Week 8 (mITT and PP, 41.3%).
These data suggest Mg–vitamin B6 relieved stress more rapidly during the treatment period
compared with Mg alone, which may indicate a more rapid onset of action associated with
Mg–vitamin B6 than with Mg alone. These results demonstrate that the combination of mag-
nesium and vitamin B6 was 24% more effective in reducing stress compared with magnesium
alone in this subgroup of severely stressed healthy adults. The beneficial effects of Mg–vitamin

B6 in severely stressed healthy adults may be attributed to the complementary effects of Mg

and vitamin B6, which have been demonstrated clinically in a number of studies using differ-
ent psychometric and laboratory measures [14]. In a cohort of 9 healthy female volunteers,
high-dose vitamin B6 (100 mg twice a day for four weeks) was shown to enhance Mg concen-
trations in plasma and red blood cells [15]. Clinical trials have clearly demonstrated the superi-
ority of vitamin B6 (40–50 mg per day) in combination with Mg (200–250 mg per day) over
Mg alone on subjective measures of anxiety and mild depression in women with premenstrual
syndrome [33, 34], and the superiority of Mg–vitamin B6 over placebo in reducing anxiety
[17]. This has led to the hypothesis that Mg–vitamin B6 influences anxiety states via modera-
tion of the stress response [17], possibly by vitamin B6 facilitating cellular uptake of magne-
sium by limiting its excretion and increasing its effectiveness [15]. In addition, a prospective
intervention trial evaluating Mg–vitamin B6 supplementation over 6 to 8 weeks reported
improvements in autonomic nervous system function and perceived stress (as measured by
the Ray-Holmes Life Events Scale) in women with stress and low serum magnesium concen-
trations [35]. Furthermore, the addition of vitamin B6 to a magnesium supplement could
reduce the risk of homocysteinemia, thus providing additional benefits [36]. The results of the
current trial add to this body of literature, and suggest that the complementary effects of Mg in
combination with vitamin B6 are more pronounced in people with severe and extremely
severe stress compared with moderately stressed individuals.
Everyday stress is a part of modern life and can be a major influencer on mood, sense of
well-being, behavior and health [37]. Daily stressors have been shown to predict the emergence
of both physical and mental health problems including influenza-like illness, sore throat, head-
aches and symptoms of depression and anxiety [38, 39]. Higher levels of perceived overall
workplace stress correlate with greater degrees of both depressive and anxiety symptoms [40].
Chronic physical conditions linked to long-term negative reactivity to stressors include diges-
tive, pain and urinary bladder disorders, which are in turn associated with psychological rami-
fications and high healthcare costs [41]. Approximately 60% of subjects in the current trial had
severe to extremely severe stress (DASS-42 stress subscale score >25); thus the impact of stress
on the lives of these individuals is likely to be high, and the benefits of the observed reductions
in stress, if maintained over the long term, could have considerable positive effects on the
physical and mental health of these individuals.
The safety profiles of both Mg–vitamin B6 and Mg were comparable and consistent with
their respective labels (Magne B6 SmPC; Magnespasymyl SmPC) [16, 42]. The overall inci-
dence of AEs and treatment-related AEs was slightly lower in the Mg–vitamin B6 arm com-
pared with the Mg arm, and the most frequent AEs occurred at a similar frequency for both
interventions. Only one participant (in the Mg arm) experienced a SAE, which was considered
unrelated to treatment. No safety concerns related to the use of magnesium with or without
vitamin B6 in stressed individuals with low serum magnesium concentration were highlighted
by this trial.
In conclusion, both Mg–vitamin B6 and Mg alone reduced stress from baseline to Week 8
by approximately 40% in the overall adult population sample studied here, with no difference
between arms. In people with severe or extremely severe stress with low serum magnesium
concentration, the Mg–vitamin B6 combination provided a 24% greater reduction in stress
than Mg alone at Week 8. These clinical data support the use of Mg supplementation to reduce
stress in stressed adults with low serum magnesium concentrations. In addition, the results
provide clinical support for a superior benefit of Mg combined with vitamin B6 in a 10:1 ratio
(in the present study, Magne B6 SmPC) in adults with severe stress. Studies of longer duration
are warranted to determine whether the effects seen can be maintained beyond 8 weeks.

Supporting information
S1 Protocol. Redacted study protocol. Redacted study protocol.
(PDF)
S2 Protocol. Protocol publication approval form. Protocol publication approval.
(DOCX)
S1 Infographic. An infographic illustrating the study and its overall findings.
(PDF)
S1 Table. CONSORT checklist. CONSORT checklist.
(DOC)
Acknowledgments
Thanks to all the subjects and their families.
The authors would like to acknowledge Patrick Griffin, MSc, of iMed Comms, Macclesfield,
UK, an Ashfield Company, part of UDG Healthcare plc for medical writing support that was
funded by Sanofi-Aventis Groupe, Gentilly, France, in accordance with Good Publications
Practice (GPP3) guidelines (http://www.ismpp.org/gpp3).
Author Contributions
Conceptualization: Etienne Pouteau.
Formal analysis: Marmar Kabir-Ahmadi.
Investigation: Etienne Pouteau, Lionel Noah, Andre Mazur, Louise Dye, Juliane Hellhammer,
Gisele Pickering, Claude Dubray.
Methodology: Etienne Pouteau.
Project administration: Etienne Pouteau.
Validation: Marmar Kabir-Ahmadi.
Writing – original draft: Etienne Pouteau, Marmar Kabir-Ahmadi, Lionel Noah, Andre
Mazur, Louise Dye, Juliane Hellhammer, Gisele Pickering, Claude Dubray.
Writing – review & editing: Etienne Pouteau, Marmar Kabir-Ahmadi, Lionel Noah, Andre
Mazur, Louise Dye, Juliane Hellhammer, Gisele Pickering, Claude Dubray.
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Superiority of Magnesium and Vitamin B6 Over Magnesium Alone On Severe Stress in Healthy Adults With Low Magnesemia: A Randomized, Single-Blind Clinical Trial

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Superiority of Magnesium and Vitamin B6 Over Magnesium Alone On Severe Stress in Healthy Adults With Low Magnesemia: A Randomized, Single-Blind Clinical Trial

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RESEARCH ARTICLE

Superiority of magnesium and vitamin B6

OPEN ACCESS Abstract

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 1 / 17

Funding: The study was funded by Sanofi-Aventis Conclusions

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 2 / 17

A combination of magnesium lactate dehydrate and pyridoxine hydrochloride in a 10:1

Fig 1. CONSORT flowchart. AE, adverse event; Mg, magnesium.

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 3 / 17

Standard protocol approvals, registration and participant consents

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 4 / 17

Outcome variables and assessments

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 5 / 17

Randomization and blinding

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 6 / 17

Baseline demographics and characteristics

Table 1. Participant demographic and disease characteristics at baseline (mITT population).

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 7 / 17

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 8 / 17

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 9 / 17

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 10 / 17

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 11 / 17

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 12 / 17

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 13 / 17

B6 in severely stressed healthy adults may be attributed to the complementary effects of Mg

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 14 / 17

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 15 / 17

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 16 / 17

PLOS ONE | https://doi.org/10.1371/journal.pone.0208454 December 18, 2018 17 / 17

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